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Norton Sound Economic Development Corporation

Norton Sound Residency Verification Form

Personal Information

Name: ______________________________________

Birthdate: ______________________

Address: _______________________________________________________________________

Communities in which you have lived in the past year: __________________________________

Phone Number: __________________________ Email or Fax: ____________________________

This Residency Verification Form is being submitted as part of the application for: ____________

_______________________________________________________________________________

Residency Statements

I am submitting this form as proof that I qualify as a Norton Sound resident under NSEDC’s

Norton Sound Residency Policy. I understand that this means that I can answer “yes” to all of

the following “Residency Statements”:

1. I have established residency by being physically present in the Norton Sound region for at

least one year and consider it my home.

2. I intend to remain in the Norton Sound region indefinitely.

3. I have not claimed residency outside of the Norton Sound region, or obtained a benefit as a

result of a claim of residency in a community outside of the Norton Sound region, at any time

in the previous year.

4. If physically absent from the Norton Sound region for more than 60 days in the prior year, I

was absent for an Allowable Absence. I have either (PLEASE CHECK ONE):

 Not been physically absent from the region for more than 60 days in the prior year; or

 I have been physically absent for more than 60 days in the prior year, but the absence

was due to the following Allowable Absence(s): ______________________________

______________________________________________________________________

Representations and Understandings

By signing this form, I am representing that I understand and agree with the following:

 All of the information provided on this form is true and accurate.

 NSEDC may request documentation to verify my responses to the Residency Statements and

to verify that an absence qualifies as an Allowable Absence and I can provide such

documentation upon request by NSEDC staff.

 Residency alone does not qualify me for participation or receipt of a benefit and I am aware

that NSEDC may adopt exceptions or more stringent requirements for certain programs.

 If an Allowable Absence is claimed, then I have not been gone from the region for any other

purpose for more than 45 days in the past year. Further, for all Allowable Absences, I have

returned to the Norton Sound region following each period of allowable absence and

otherwise acted consistently with an intention to remain a resident of the region.

Signature: _____________________________________________ Date: ____________________

FOR NSEDC INTERNAL USE ONLY – PLACE IN APPLICATION FILE WHEN COMPLETE

DATE RECEIVED: __________________________________

RECEIVED BY: ________________________________

DATE APPROVED: _________________________________

APPROVED BY: _____________________________

FLAGGED FOR FURTHER REVIEW? NO YES: __________________________________________________________

Adopted May 2014

Norton Sound Residency Verification Form - Norton Sound Economic Development Corporation

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